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Pancreatic cancer has an extremely poor prognosis and prolonged survival is achieved only by resection with macroscopic tumor clearance. There is a strong rationale for a neoadjuvant approach, since a relevant percentage of pancreatic cancer patients present with non-metastatic but locally advanced disease and microscopic incomplete resections are common. The objective of the present analysis was to systematically review studies concerning the effects of neoadjuvant therapy on tumor response, toxicity, resection, and survival percentages in pancreatic cancer. Trials were identified by searching MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials from 1966 to December 2009 as well as through reference lists of articles and proceedings of major meetings. Retrospective and prospective studies analyzing neoadjuvant radiochemotherapy, radiotherapy, or chemotherapy of pancreatic cancer patients, followed by re-staging, and surgical exploration/resection were included. Two reviewers independently extracted data and assessed study quality. Pooled relative risks and 95% confidence intervals were calculated using random-effects models. Primary outcome measures were proportions of tumor response categories and percentages of exploration and resection. A total of 111 studies (n = 4,394) including 56 phase I-II trials were analyzed. A median of 31 (interquartile range [IQR] 19-46) patients per study were included. Studies were subdivided into surveys considering initially resectable tumors (group 1) and initially non-resectable (borderline resectable/unresectable) tumors (group 2). Neoadjuvant chemotherapy was given in 96.4% of the studies with the main agents gemcitabine, 5-FU (and oral analogues), mitomycin C, and platinum compounds. Neoadjuvant radiotherapy was applied in 93.7% of the studies with doses ranging from 24 to 63 Gy. Averaged complete/partial response probabilities were 3.6% (95% CI 2%-5.5%)/30.6% (95% CI 20.7%-41.4%) and 4.8% (95% CI 3.5%-6.4%)/30.2% (95% CI 24.5%-36.3%) for groups 1 and 2, respectively; whereas progressive disease fraction was estimated to 20.9% (95% CI 16.9%-25.3%) and 20.8% (95% CI 14.5%-27.8%). In group 1, resectability was estimated to 73.6% (95% CI 65.9%-80.6%) compared to 33.2% (95% CI 25.8%-41.1%) in group 2. Higher resection-associated morbidity and mortality rates were observed in group 2 versus group 1 (26.7%, 95% CI 20.7%-33.3% versus 39.1%, 95% CI 29.5%-49.1%; and 3.9%, 95% CI 2.2%-6% versus 7.1%, 95% CI 5.1%-9.5%). Combination chemotherapies resulted in higher estimated response and resection probabilities for patients with initially non-resectable tumors (\"non-resectable tumor patients\") compared to monotherapy. Estimated median survival following resection was 23.3 (range 12-54) mo for group 1 and 20.5 (range 9-62) mo for group 2 patients. In patients with initially resectable tumors (\"resectable tumor patients\"), resection frequencies and survival after neoadjuvant therapy are similar to those of patients with primarily resected tumors and adjuvant therapy. Approximately one-third of initially staged non-resectable tumor patients would be expected to have resectable tumors following neoadjuvant therapy, with comparable survival as initially resectable tumor patients. Thus, patients with locally non-resectable tumors should be included in neoadjuvant protocols and subsequently re-evaluated for resection.

Surgical resection and endoscopic resection comprise two alternative options for the treatment of submucosal tumors (SMTs) originating from the muscularis propria (MP) layer. Endoscopic resection is minimally invasive compared with surgical resection. Conventional non-tunneling techniques, such as endoscopic submucosal dissection (ESD), endoscopic submucosal excavation (ESE), and endoscopic full-thickness resection (EFR) have been demonstrated to be safe and effective. However, these techniques fail to maintain the integrity of the mucosa and induce high risk of perforation, infection, and postoperative strictures. Submucosal tunneling endoscopic resection (STER) is a novel surgical technique that can maintain the integrity of the mucosa by establishing a tunnel between the submucosal and the MP layers. STER has been proven to be effective and safe for the treatment of SMTs. Currently, STER has become a standard treatment for gastrointestinal (GI) SMTs originating from the MP layer, notably in China. In the present review, we describe the indications, procedures, postoperative care, efficacy and safety outcomes, and future perspectives of STER for GI SMTs originating from the MP layer.

Background The most common site of gastrointestinal stromal tumors (GISTs) is the stomach, and gastric GISTs (gGISTs) occur most often in elderly patients. However, the clinicopathological features, treatment patterns, and prognosis of elderly patients with gGISTs remain unclear. Methods We retrospectively collected clinicopathological and prognostic data for patients with primary gGISTs who underwent curative-intent resection at 10 medical centers in China from 1998 to 2015. Results Over the 18 years, 10 medical centers treated 1846 patients with primary gGISTs by curative-intent resection. The median age was 59 (range 18–91) years. The patients were classified into two groups according to age, namely an elderly group (≥ 65 years of age) and a nonelderly group (< 65 years of age). The elderly group had more comorbidities (40.7% vs 23.5%, p  = 0.011), a higher rate of postoperative complications (14.4% vs 8.7%, p  = 0.031), and a lower proportion of intermediate/high-risk patients who received adjuvant therapy (30.0% vs 66.8%, p  = 0.001) than did the nonelderly group. Regarding pathological outcomes, a significant difference in tumor necrosis was observed between the two groups ( p  = 0.002), and more cases of tumor necrosis occurred in the elderly group than in the nonelderly group. Regarding postoperative recovery outcomes, no significant difference was observed between the two groups . Univariate analysis showed that age, postoperative complications, adjuvant therapy, tumor size, mitotic count, modified National Institutes of Health (NIH) risk category, and tumor necrosis were factors that affected disease-free survival (DFS). Multivariate analysis showed that modified NIH risk category was the only independent factor affecting DFS. The 5-year DFS rates in the nonelderly and elderly groups were 88.1% and 81.4%, respectively ( p  = 0.034), and the 5-year overall survival (OS) rates were 90.4% and 85.5% ( p  = 0.038), respectively. Conclusions Currently, the treatment patterns for elderly patients with gGISTs remain the same as those for young patients with gGISTs. Elderly gGIST patients had more comorbidities and postoperative complications than did nonelderly gGIST patients, and fewer elderly gGIST patients received postoperative adjuvant therapy. Elderly gGIST patients also had a higher rate of tumor necrosis and worse DFS and OS than did young gGIST patients. Further exploration into the diagnosis and treatment patterns of elderly patients is therefore essential.

An air-fluid level within a gastrointestinal stromal tumor (GIST) is unusual and indicates the presence of a fistula within the lumen of the GI tract. Until recently, the optimal management of such patients was not clear-cut. This retrospective study investigated the clinicopathological characteristics, surgical procedures, pre-and post-operative management, and prognosis of patients with GIST containing an air-fluid level. Data of GIST patients, spanning 5 years, including 17 GIST patients with air-fluid levels in the experimental group and 34 GIST patients without air-fluid levels in the control group, were retrieved from two hospitals in China. The clinicopathological characteristics, types of surgery, management, and clinical outcomes of GIST patients were compared between the two groups. GISTs containing air-fluid levels were significantly different from GISTs without air-fluid levels regarding tumor morphology, NIH risk category, invasion of adjacent organs, and necrosis or ulceration. Most GIST patients with air-fluid levels (14/17, 82.4%) received open surgery, significantly higher than the 20.6% in the control group. Targeted therapy with Imatinib mesylate (IM) was implemented in all GIST patients in the experimental group (17/17, 100%); markedly higher than those (3/34, 8.8%) in the control group. During follow-up, recurrence and death rates (5.9% and 5.9%) in the experimental group were higher than those (2.9% and 0%) in the control group. Open surgery is commonly performed in GIST patients with air-fluid levels who also require targeted therapy with IM. The Torricelli-Bernoulli sign could be a risk factor, adversely affecting the patient's prognosis.

Background Surgical phase recognition using computer vision presents an essential requirement for artificial intelligence-assisted analysis of surgical workflow. Its performance is heavily dependent on large amounts of annotated video data, which remain a limited resource, especially concerning highly specialized procedures. Knowledge transfer from common to more complex procedures can promote data efficiency. Phase recognition models trained on large, readily available datasets may be extrapolated and transferred to smaller datasets of different procedures to improve generalizability. The conditions under which transfer learning is appropriate and feasible remain to be established. Methods We defined ten operative phases for the laparoscopic part of Ivor-Lewis Esophagectomy through expert consensus. A dataset of 40 videos was annotated accordingly. The knowledge transfer capability of an established model architecture for phase recognition (CNN + LSTM) was adapted to generate a “Transferal Esophagectomy Network” (TEsoNet) for co-training and transfer learning from laparoscopic Sleeve Gastrectomy to the laparoscopic part of Ivor-Lewis Esophagectomy, exploring different training set compositions and training weights. Results The explored model architecture is capable of accurate phase detection in complex procedures, such as Esophagectomy, even with low quantities of training data. Knowledge transfer between two upper gastrointestinal procedures is feasible and achieves reasonable accuracy with respect to operative phases with high procedural overlap. Conclusion Robust phase recognition models can achieve reasonable yet phase-specific accuracy through transfer learning and co-training between two related procedures, even when exposed to small amounts of training data of the target procedure. Further exploration is required to determine appropriate data amounts, key characteristics of the training procedure and temporal annotation methods required for successful transferal phase recognition. Transfer learning across different procedures addressing small datasets may increase data efficiency. Finally, to enable the surgical application of AI for intraoperative risk mitigation, coverage of rare, specialized procedures needs to be explored. Graphical abstract

Background Prolonged postoperative ileus (PPOI) is among the common complications adversely affecting postoperative outcomes. Predictors of PPOI after major abdominal surgery remain unclear, although various PPOI predictors have been reported in patients undergoing colorectal surgery. This study aimed to devise a model for stratifying the probability of PPOI in patients undergoing abdominal surgery. Methods Between 2012 and 2013, 841 patients underwent major abdominal surgery after excluding patients who underwent less-invasive abdominal surgery, ileus-associated surgery, and emergency surgery. Postoperative managements were generally based on enhanced recovery after surgery (ERAS) program. The definition of PPOI was based on nausea, no oral diet, flatus absence, abdominal distension, and radiographic findings. A nomogram was devised by evaluating predictive factors for PPOI. Results Of the 841 patients, 73 (8.8%) developed PPOI. Multivariable logistic regression analysis revealed smoking history ( P  = 0.025), colorectal surgery ( P  = 0.004), and an open surgical approach ( P  = 0.002) to all be independent predictive factors for PPOI. A nomogram was devised by employing these three significant predictive factors. The prediction model showed relatively good discrimination performance, the concordance index of which was 0.71 (95%CI 0.66–0.77). The probability of PPOI in patients with a smoking history who underwent open colorectal surgery was calculated to be 19.6%. Conclusions Colorectal surgery, open abdominal surgery, and smoking history were found to be independent predictive factors for PPOI in patients who underwent major abdominal surgery. A nomogram based on these factors was shown to be useful for identifying patients with a high probability of developing PPOI.

Background: Residing in a disadvantaged areas or neighborhoods has been associated with disease burden, health behaviors, and stress levels. Within bariatric populations, patient-level socio-economic status (SES) has been associated with short and long-term weight change, peri- and post-operative outcomes, and quality of life indictors. Our objective was to evaluate the relationship of a Census Tract- I evel SES index with baseline and 8 year BMI outcomes in an adolescent bariatric cohort. Methods: Teen-LABS, a prospective observational study at five US centers, enrolled consecutive bariatric surgery cases of patients <19 yrs (N = 242). A total of 228 (94%) baseline addresses were geocoded and linked to Census tract- I evel SES metrics. Principal components analysis was used to develop a composite SES index based on these measures. Baseline and 8 year BMI were evaluated by SES index (categorized as: low, medium, high by tertile distribution) using regression modeling. Results: Participants lived a median distance of 29 miles from their clinical center at baseline. Non-white and Hispanic participants more frequently resided in lower SES areas (each p < 0.05). Adjusted analyses found that baseline BMI was significantly greater for those residing in low SES (mean BMI: 54.8) vs. high SES (49.9) areas (p < 0.01). Also, 8 years after surgery, mean %BMI change from baseline was -13.7% among those in the lowest SES area, compared to -20.0% from high SES areas (p = 0.01). Conclusions: Participants residing in lower SES areas presented with higher BMIs and had poorer BMI outcomes 8 years after surgery. Future work should seek to further clarify the relationships between residential SES and long-term bariatric outcomes.

Background: (1) To explore the relationship between the magnitude of weight loss after bariatric surgery (BS) and post-surgical major adverse cardiovascular outcomes (MACE) incidence, (2) To compare the performance of <50% excess weight loss (EWL), <20% total body weight loss (TBWL), and -1 standard deviation in percentage of alterable weight loss (-1SD%AWL) as insufficient weight loss (IWL) measures for its association with MACE.Whether the extent of weight loss achieved after BS modulates cardiovascular benefits has seldom been assessed. Several weight-loss thresholds have been commonly used to classify BS-patients as good or poor responders without demonstrating its clinical relevance. Methods: Longitudinal observational study including 1700 individuals who underwent BS in a single institution between Jan-2005 and Dec-2014. Cox proportional hazard models were used to assess the relationship between 1-year and 5-year weight change and the time to first post-surgical MACE. Results: During a mean follow-up of 10.2 ± 2.8 years, 86 participants (5.2%) experienced a first post-surgical MACE. Higher weight loss at one-year (HR: 0.77 (95%CI: 0.61-0.098)) and 5-year (HR: 0.63 (95%CI: 0.42-0.092)) was related to a lower incidence of MACE. All short-term criteria for defining IWL were similarly associated with MACE, but -1SD%AWL identified more subjects at risk. Five-year TBWL < 20% and 5-year -1SD-AWL% were significantly associated with a higher risk for cardiovascular (CV) events. TBWL < 20% identified more subjects at risk. Conclusions: The extent of weight loss is closely related to long-term MACE incidence. Patients who lost -1SD%AWL at 1-year or <20% TBWL at 5-year may be considered poor responders.